Provider Demographics
NPI:1285091181
Name:SOUTHERN NEW MEXICO ORTHODONTICS LLC
Entity type:Organization
Organization Name:SOUTHERN NEW MEXICO ORTHODONTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:EBONIE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BOGDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-892-9010
Mailing Address - Street 1:1310 E PINE ST STE B
Mailing Address - Street 2:
Mailing Address - City:DEMING
Mailing Address - State:NM
Mailing Address - Zip Code:88030-7003
Mailing Address - Country:US
Mailing Address - Phone:575-544-9999
Mailing Address - Fax:575-546-1070
Practice Address - Street 1:1310 E PINE ST STE B
Practice Address - Street 2:
Practice Address - City:DEMING
Practice Address - State:NM
Practice Address - Zip Code:88030-7003
Practice Address - Country:US
Practice Address - Phone:575-544-9999
Practice Address - Fax:575-546-1070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-22
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD4435122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty